1	Assessment of Temporal Processing – Is it Worth the Time? Instructional Course presented to: American Academy of Audiology April 5, 2003 Robert W. Keith, Ph.D. University of Cincinnati
2	FUNDAMENTALS OF AUDITORY ANALYSIS Frequency - Pitch Intensity - Loudness Duration - Time
3	Temporal Processing as a Cortical Function
4	Temporal Processing Disorders Time not Lobe!
5	Models of CAPD Tallal - Temporal processing disorder: The inability to accurately perceive auditory signals of brief duration when presented at rapid rates.
6	Four Hypotheses explaining CAPD Jerger (1998) Seminars in Hearing Auditory Memory Deficit Auditory Sequencing Deficit Temporal Resolution Deficit Figure Ground Deficit
7	Models of CAPD Keith model of CAPD Neurologic abnormalities/maturational delays Temporal processing deficits Deficient selective listening/channel separation Deficient auditory processing in noise
8	A conceptual framework for auditory processing/language disorders Language employs pitch, duration, and rhythm Tonal and temporal characteristics . . . have consequences for auditory processing and language learning (from Chelfant-Evans, 2000) As a result we are interested in identifying the basis of disorders of pitch, duration (time) and rhythm
9	A conceptual framework for auditory processing/language disorders Grammatical morphemes with short duration pose problems for speech-language impaired children (Drommi et al., 1993) We are interested in identifying temporal processing disorders in children who are unable to hear short duration morphemes
10	A conceptual framework for auditory processing/language disorders: Phonologic working memory Acoustic, temporal (timing) and sequential aspects of sound are represented in a sensory trace (echoic memory) before fading. The sensory trace is translated into “phonologic coding” and stored into long term memory (Cowan, 1995) We are interested in identifying disorders of short term memory and temporal processing.
11	Central Auditory Processes Responsible for the following Phenomenon (ASHA, 1996) Sound localization and lateralization Auditory discrimination Auditory pattern recognition Temporal aspects of audition -Temporal resolution -Temporal masking -Temporal ordering Performance with competing signals Performance with degraded signals
12	Bruton Conference (JAAA 2000) Definition of APD An auditory processing disorder (APD) is defined as a deficit in the processing of information in the auditory modality.
13	Bruton Consensus Conference on the Diagnosis of APD in School-Aged Children: Minimal APD Test Battery Behavioral measures Pure tone audiometry P-I functions for word recognition Dichotic task (digits, words, and/or sentences) Duration pattern sequence test Temporal gap detection Electrophysiologic measures Immittance audiometry Otoacoustic emissions ABR MLR P300 (optional)
14	Temporal Processing Disorders We try to identify timing disorders in the auditory system to explain why some patients have difficulty with auditory discrimination, phonics, and reading. With this information appropriate remediation can be implemented.
15	Acoustic Spectrum of “Mouth”
16	Acoustic Spectrum of “sing”
17	Temporal Processing Disorders i.e. Tests for disorders of auditory timing
18	Tests of Temporal Processing Abilities ABR – Click Rate Function Temporal Integration – Brief Tone Audiometry (Zwislocki, 1960 – Wright, 1968) Acoustic Reflex Latency Tests (Garza) Masking Level Differences (Wilson et al. 1994) Auditory Fusion Test-Revised (McCroskey and Keith 1996) Random Gap Detection Test (Keith 2000) Time Compressed Sentence Test (Keith2002) Duration Patterns Test (Musiek, 1994)
19	Auditory Brainstem Responses Click Rate Function Wave V latency increases ~ .10 msec for every 10/sec increase in click rate Click rate changes cause abnormally long latencies in patients with brainstem lesions ABR click rate function may be used to study temporal processing disorders at the brainstem level
20	Temporal Integration (Temporal Auditory Summation) Auditory threshold decreases as tone duration increases (Zwislocki, 1960) Normal threshold decrease is 10dB with duration increase from 20 to 200 msec Temporal integration is “absent” in cochlear lesions (Wright 1968, 1969) Brief tone audiometry may be used to study temporal processing at the level of the cochlea
21	Masking Level Differences Measures brain stem level function Binaural release from masking is approximately 5 to 12 dB depending on stimuli Test materials available on VA CD 2.0 Few norms available for children No current clinical application for remediation beyond understanding the auditory system.
22	VA CD Recording for Auditory Perceptual Assessment: Disc 2.0 MLD’s for Spondees and Broadband Noise Dichotic Listening to Musical Cords Dichotic Listening to Speech: Digits, Sentences, and Nonsense Syllables Low- and High-Pass Filtered NU-6 Frequency and Duration Pattern Tests Time Compression and Time Compression plus Reverberation on NU-6
23	MLD for Spondaic Words in 2000-msec Bursts of Broadband Noise (Wilson et al.1994) Antiphasic condition w/ speech and noise 180 degrees out of phase Ten 500 msec spondaic words embedded into 2000-msec noise bursts Mean MLD- 9.5 dB (+/- 1.1 dB)
24	Wichita Auditory Fusion Test Robert McCroskey (1984)
25	Auditory Fusion Test-Revised (AFT-R) McCroskey and Keith, 1996 Purpose: To investigate temporal aspects of audition by measuring the auditory fusion threshold of tone pairs separated in time between 0 and 300 msec.
26	Auditory Fusion Test-Revised McCroskey and Keith 1996 Five Frequencies Three subtests Tone pairs with ISI 0-300 msec Auditory fusion is ISI when two tones are heard as one Normal AF - 10 msec + or - 4 AFT-R may be useful for studying temporal processing disorders at the cortical level
27	Auditory Fusion Test-Revised McCroskey RL and Keith RW (1996) Screening AFT 0-300 mSec (ascending) Standard AFT 0-40 mSec* Expanded AFT 40-300 mSec* *ascending and descending
28	AFT-R Normative Data
29	Comments on the AFT-R Test takes a long time to administer Ascending intervals may be predictable Some frequencies do not provide useful diagnostic information Provides information on temporal processing up to 300 msec.
30	Random Gap Detection Test - The next generation Keith (2000) Purpose: To investigate temporal aspects of audition by measuring the auditory fusion threshold of tone pairs or clicks separated in time between 0 and 40 msec.
31	Random Gap Detection Test (RGDT) Keith (2000) Tone pairs at 500, 1000, 2000 and 4000 Hz and pairs of clicks. Time intervals (gaps) between stimuli range from 0 to 40 msec.
32	Random Gap Detection Test Keith (2000) Example of inter-stimulus interval (gap) order of presentation in msec: 20 - 2 - 40 - 5 - 10 - 25 - 15 - 0 - 30
33	Random Gap Detection Test 1000 Hz (Keith, 2000) Recorded by Auditec of St. Louis Bill Carver, Ph.D.
34	Random Gap Detection Test 4000 Hz (Keith, 2000) Recorded by Auditec of St. Louis Bill Carver, Ph.D.
35	Random Gap Detection Test (RGDT) Keith (2000) The gap detection threshold is defined as the time interval at which the stimuli are detected as two tones rather than one. A gap detection threshold >20 msec. is considered abnormal indicating a temporal processing disorder.
36	RGDT Normative Data (2001) Mean of each age group: age 5: 4.2 age 6: 3.5 age 7: 9.5 age 8: 5.5 age 9: 7.2 age 10: 9.6 age 11: 6.8 age 12: 8.7 SD of each age group: age 5: age 6: age 7: 4.1 age 8: 4.4 age 9: 4.5 age 10: 4.5 age 11: 2.7 age 12:
37	RGDT Normative Data (2001)
38	Random Gap Detection Test - Expanded (RGDT) Keith (2000) Intended for individuals whose gap detection threshold exceeds 40 msec. Includes time intervals between 50 and 300 msec. Administered in the same manner as the RGDT Useful as “practice” for administering the RGDT
39	RGDT – Hints for scoring Instruct, demonstrate, and practice include RGDT Expanded Administer the “practice” Repeat until sure that instructions are understood Ignore obvious outliers 20 - 2 - 40 - 5 - 10 - 25 - 15 - 0 - 30 Move to Expanded if unable to respond to 40 msec. Abandon the test if child is totally random for everything
40	RGDT Click Stimuli “A screening test procedure should include the following elements . . . . . . a gap-detection test in which a short silent gap is inserted in a burst of broad band noise.” (Jerger and Musiek, 2000).
41	Time Compressed Sentence Test
42	Time Compressed Speech Time compression above 50% results in marked loss of speech discrimination Optimal time compression of 50% agrees with assumptions that 50% of natural speech is redundant Time compressed speech can be used to assess information processing speed (Letowski & Poch, 1996) Time compression results in degraded speech signal, but does not assess temporal processing as such
43	Time Compressed Words (Wilson et al. 1994) NU No. 6 monosyllable words Female speaker Time compressed at 45 and 65% Slope of function between 20 and 80% correct is 2.8% per dB at 45% compression and 2.0% per dB at 65% compression
44	Time Compressed Sentence Test Measures a child’s response to meaningful sentences that are time compressed at 40% and 60% The only other available time compressed test utilizes monosyllable words. Time compressed sentences are a more realistic stimuli since they represents typical speech more normally
45	Time Compressed Sentence Test: What does it measure? Test of temporal processing Inability to hear rapid format frequency transitions Inability to process auditory information at rapid rates of speech May correlate with gap detection thresholds Test of degraded speech Distorted speech similar in concept to filtered words and auditory figure ground
46	Time Compressed Sentence Test (Keith 2002) One list of practice sentences at 0% TC Two lists of sentences TC at 40% Two lists of sentences TC at 60% Each TC list preceded by 2 practice sentences Available from Auditec of St. Louis
47	Time Compressed Sentence Test: Example of 40% TC Mother / cut / the bread. The boy / fell / in the water. The dog / caught / a rabbit. Father / drives / a car. The girl / helped / her mother.
48	Time Compressed Sentence Test: Example of 60% TC The woman / washed / the floor. The cat / chased / a mouse. The baby / hurt / his finger. Mother / sent for / the doctor. The duck / swam / on the water.
49	Time Compressed Sentence Test (Keith 2002) Mother made a cake. The boys played football. The mother cut the bread. The boy fell in the water. Father drives a car. The girl helped her mother Etc. Recorded and available from Auditec of St. Louis
50	Time Compressed Sentence Test (Keith 2000): Scoring Three points for each sentence repeated correctly, one point deducted for each section of the sentence (subject, object, or predicate) misinterpreted or not heard. The score is reported in percent
51	Time Compressed Sentence Test: Normative Data Data collection by 11 Beta sites across the USA, in multiple geographic regions and among various racial, ethnic, and socio-economic groups.
52	Time Compressed Sentence Test Normative data obtained by 13 audiologists 7 States 3 University clinic 4 Public school setting 2 Private practice
53	Time Compressed Sentence Test: Normative Data Subjects in each age group from 6 to 9 years and age 10+11. All attended regular classrooms Normal hearing and middle ear function. Native speakers of English
54	Time Compressed Sentence Test: Subjects N = 163 76 boys and 87 girls Race White = 119 Black = 16 Hispanic = 19 Asian = 1 Native American = 1 Multiracial = 7
55	Time Compressed Sentence Test: Subjects by age Six years = 21 Seven years = 35 Eight years = 39 Nine years = 37 Ten-eleven years = 31 Total = 163
56	Time Compressed Sentence Test 3.3 points scored for each correct sentence. One point deduced for each section missed. Score converted to percent (%) correct.
57	Scoring the Time Compressed Sentence Test: Example at 40% TC Mother / cut / the bread. - 0 The boy / fell - swam/ in the water. - 1 The dog / caught / a rabbit. - 1 Father / drives / a car. - 2 The girl / helped / her mother. -3
58	Time Compressed Sentence Test: Scoring and Interpretation Raw scores in number of errors Convert to percent correct Interpret as normal, borderline, or abnormal performance Look up Z-scores and percentiles Convert percentiles to Standard Scores Analysis of ear differences
59
60	Time Compressed Sentence Test: Mean performance by age and condition
61	Time Compressed Sentence Test: Standard Deviation
62	Time Compressed Sentence Test - Spanish Version Keith (2002)
63	Examples of TCST- Spanish Sentences 1 - El policía / persiguió / al ladrón. 2 - Algunos rancheros / crían / vacas. 3 - El cartero / trae / las cartas. 4 - El profesor / contó / la historia. 5 - La niña / compró / un vestido nuevo.
64	TCST-Spanish Version Normative Data Data is being collected by - - -
65	Duration Pattern Test (Musiek, et al, 1990) Three 1000 Hz tones and two 300 msec intertone intervals Tones are 250 or 500 msec in duration Six possible combinations of the three-tone sequence (LLS, LSL, LSS, SLS, SLL, SSL) VA CD contains 60 patterns (6 patterns and 10 randomizations w/ 6-sec interpattern intervals
66	Duration Patterns Test (Musiek et al, 1990) Effective in identifying temporal lobe lesions, among others DPT may be used to study temporal processing at cortical levels
67	Duration Patterns Test (Musiek, et al, 1990) LSS ^{__________ _____ _____} SLS ^{_____ __________ _____} SSL ^{_____ _____ __________} LLS ^{__________ __________ _____} LSL ^{__________ _____ __________} SLL ^{_____ __________ __________}
68	Duration Patterns Test Musiek et al (1990) Performance below 70% correct is considered abnormal, indicating cortical based APD. No normative data have been developed for children.
69	Frequency Patterns Test Musiek, FE. (1994) Frequency (Pitch) and Duration Pattern Tests. Journal of the American Academy of Audiology, Volume 5 (4), 265– 268.
70	Frequency Patterns Test Three Tone Burst Patterns LHL, HLH,LLH, HHL, HLL,LHH If first 14 of 15 responses are correct stop the test, if not, continue to 30 items. (Musiek, 1994, Frequency and Duration Pattern Test, JAAA, 5: 265)
71	Frequency Patterns Test: Normative Cut-off Scores AGE LE RE 8yrs 40% 40% 9 yrs 65% 65% 10 yrs 72% 72% 11 yrs 75% 75%
72	Another category of persons with APD who have problems with “Speed of Auditory Processing” Characterized by difficulty maintaining the “pace” of ordinary conversation Borderline but not profoundly abnormal auditory processing abilities
73	18 YO Female with borderline AP Abilities - PA Family history of APD with affected father and brother Complaint of “distracted by noise”, difficulty listening in the classroom and following directions, requests repeat of information frequently, difficulty following conversations.
74	18 YO Female with borderline AP Abilities - PA IQ = 114 Duration Patterns Test = 100% Frequency Patterns Test = 100% RGDT = 2 msec. Time Compressed Sentence Test = SS of 55 SSW NOE = normal All responses to speech stimuli were delayed, with “last minute responses.”
75	18 YO Female with borderline AP Abilities - PA
76	18 YO Female with borderline AP Abilities - PA Impression: Borderline auditory processing skills with delays in speed of auditory processing
77	18 YO Female with borderline AP Abilities - PA Recommendations: Maintain perspective relative to many talents against her auditory processing skills Direct methods of coping by managing her acoustic environment Use of direct eye contact Follow compensatory recommendations that have worked for her father Continue to ask questions when she misses auditory information Do not limit college choices because of mild auditory processing deficits
78	Temporal Processing Disorders: A Quasi Hierarchy of Anatomic Site Temporal Integration Cochlear Auditory Brainstem Response Brainstem Gap Detection BS/Cortex Time Compressed Speech Cortex Duration Patterns Test Cortex
79	Recommended Central Auditory Test Battery Tests of peripheral auditory function OAE’s Monaural sensitized speech (FW, AFG) Dichotic speech tests (CW, CS, SSW) Tests of temporal processing: Brief Tone Audiometry Gap Detection Time Compressed Sentences
80	A Decision Tree for Management or Remediation (Keith, 1999) Disorders of temporal processing Perceptual training Slowing rate Disorder of auditory figure ground Reduce noise in environment Preferential seating FM system or other ALD Disorders of binaural separation/maturation Receptive and expressive language training
81	Time Compressed Sentence Test: Suggestions for remediation Teacher and parent awareness Preferential seating and increased visual cues Slow rates of speech Provide information in smaller units Computer assisted remediation
82	Modifications to the Speech Signal Increase loudness Slower rate Smaller language units Frequent language units Reauditorization
83	Computer Assisted Remediation FastForward www.scilearn.com Earobics www.cogcon.com ????
84	Remediation of persons with CAPD Tallal and colleagues Science Vol. 271, 77-84, 1996
85	Fast ForWord* “An integrated software-based training program that teaches several speech and language skills including phonics, morphology, syntax, and grammar.” * Quote from www.scientificlearning.com
86	Fast ForWord Language “Fast ForWord Language is a computer-based training program that rapidly develops the foundational skills known to be pre-requisites for reading.” Quote from www.earobics.com
87	Fast ForWord Basics™ (Away We Go!) Early Learning Games Phonological awareness Working memory Decoding Letter-name and letter-sound association Event sequencing Color, shape and size identification Following oral instructions Eye-hand coordination Memory skills
88	Fast ForWord Language Phonological awareness Sustained focus and attention Listening comprehension Language structures
89	Fast ForWord Language “On average, students who train with Fast ForWord Language make language gains of 1-2 years in just 4-8 weeks.” Quote from www.scilearn.com
90	Earobics* “Earobics uses scientifically based and clinically proven techniques to teach listening and language skills (including phonologic awareness, auditory processing and phonics skills) that make children better readers, listeners, and learners.” Quote from www.earobics.com
91	Cognitive Concepts: Earobics Software Earobics Step 1 Software (for developmental ages 4-7) Earobics Step 2 Software (for developmental ages 7-10) Earobics Step 1 for Adolescents & Adults Software (ages 10 and up)
92	Earobics Step 1 For developmental ages 4-7 Six interactive games with over 300 levels of play. Teaches phonological awareness, auditory processing and introductory phonics skills required for learning to read and spell. Develops general cognitive skills that support learning, such as attention and memory Quotation from www.earobics.com
93	Case Studies: Temporal Processing Disorders
94	Nine Year Old Male w/ Temporal Processing Disorder Auditory Fusion Test-Revised = 92 msec Time Compressed Speech RE = 44% LE = 52%* SCAN FW = 9%ile AFG = 37%ile CW = 9%ile * criterian score = 80%
95	Nine Year Old Male w/ Temporal Processing Disorder TOLD substests mean 29%ile TAPS subtests below 18%ile Lindamood = 55 (criteria = 62) Spadafore Diagnostic Reading = 1.5 grade
96	Nine Year Old Male w/ Temporal Processing Disorder Recommodations: Comprehensive Psychoeducational Eval Comprehensive Reading Eval Speech and Language Therapy Structured Classroom Oral examinations admin one on one Preferential seating, and classroom “buddy” Fast ForWord
97	Eight Year Old Girl with language delay and reading problems SCAN FW = 16 %ile AFG = 16 %ile CW = 3 %ile AFT-R = 120 msec. Time Compressed Speech RE = 20% LE = 10% SSW = 5 %ile
98	Eight Year Old Girl with language delay and reading problems TOLD = 25 to 50 %ile Token Test for Children = 16 %ile TAPS-Revised 18 - 50 %ile for memory tests 10 %ile for discrimination
99	Eight Year Old Girl with language delay and reading problems Recommendations: Multisensory approach to reading Refer to SLP for eval and Tx. Preferential Seating Slow rate of instructions and check for understanding Shorten directions into simple steps ID computer games for auditory and reading skills